Did anyone living in your home receive any of the following services in the last 12 months?

Please check all that apply?

Food Stamps

Medicare/Medicaid/SSI

Disability

Unemployment

Meals on Wheels

Is anyone living in the home disabled?

Yes

No

Please tell us which of the following apply?

Please check all that apply.

Hearing Impaired

Visually Impaired

Wheelchair user

Uses a walker/cane

Other

You selected 'Other' above. Please explain.

Please describe any other health issues that may require special attention:

Do you own the home?

Yes

No

Who owns the home?

Relationship to You

Do you have a mortgage on your home?

Yes

No

What is the monthly mortgage payment?

How many stories is your home?

Year Purchased

Year Built

Square Footage

Please describe the repairs that you need to make your home accessible, livable and safe. Hearts for Homes will consider all types of repairs, but a final decision is at their discretion, depending on time, financial resources, and the availability of volunteers with the required skills. Please be specific as possible and/or attach any additional documentation as needed to describe repairs.

If applicable, attach supporting documentation here.

Hearts for Homes will consider all types of repairs, but a final decision is at their discretion, depending on time, financial resources, and the availability of volunteers with the required skills.

If accepted, a time schedule for beginning and completing your project will be discussed with you in advance, and as little inconvenience to you and your family will be our goal.

Homeowner Agreement

HOMEOWNER AGREEMENT (Please read!)
I hereby certify that I do not plan or intend to sell my home within the next two years. I certify that I have homeowner’s insurance. I confirm that, except conditions which may be described in this application, my home and the surrounding area is a safe place for volunteers. If requested, I agree to provide additional financial records to verify the income listed in this application, ownership of property and insurance. I also understand that, because this is a volunteer organization dependent on donated services and funds, Hearts for Homes, Inc. reserves the right to revoke any acceptance of a home into its program for any reason at any time. I also confirm that any physically able person(s) residing in my home or visiting on the project day(s) agrees to work alongside Hearts for Homes volunteers.
I give Hearts for Homes permission to reprint pictures/video of myself and/or my home for its promotional literature.
I understand that the people who may work on my home are unpaid volunteers; that few (if any) of these volunteers are skilled in the building trades; and that HEARTS FOR HOMES MAKES NO WARRANTIES OR REPRESENTATIONS, EXPRESSED OR IMPLIED, ABOUT ANY OF THE MATERIALS USED OR WORK DONE BY ANYONE ON MY HOUSE; and thereby release Hearts for Homes, Inc., and all associated with it, from any and all liability arising from negligence for any personal injury or property damage arising out of or relating to the work done on my house.
BY SIGNING THIS DOCMENT, I/WE HEREBY CONFIRM THAT ALL INFORMATION IN THIS APPLICATION IS CORRECT, AND THAT I/WE UNDERSTAND AND AGREE TO THE STATED TERMS AND CONDITIONS.

To digitally sign this document, please enter your full legal name in the box below. This will be treated as a legal signature.